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A Quality and Analytics-Based Approach to the Opioid Epidemic
Session #104, February 13, 2019
Dr. Barbara Coughlin, Vice President of Quality & Payor Initiatives, HCA Healthcare Physician Services Group
Dr. Carol White, Manager of Ambulatory Pharmacy Informatics & Medication Management, HCA Healthcare Clinical Services Group
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Barbara Coughlin, DNP, MBA, RN
Carol White, PharmD, BCPS, BCGP, CPHIMS
Have no real or apparent conflicts of interest to report.
Conflict of Interest
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• Learning Objectives
• Opioid Epidemic
• Physician Perceptions
• HCA Physician Services Group
Agenda
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About Us
Dr. Carol White, Manager
Ambulatory Pharmacy Informatics and
Medication Management
HCA Healthcare, Clinical Services Group
Dr. Barbara Coughlin, Vice President
Quality and Payor Initiatives
HCA Healthcare, Physician Services Group
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• Define key components and crucial performance metrics of an
effective pain management program
• Develop a robust clinical data analytics and reporting approach for
monitoring provider prescribing compliance, including data
management and reporting visualization
• Analyze utilization of electronic health record (EHR) workflows
and standardization of data to guide provider assessment and
pain management therapy decisions
Learning Objectives
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Opioid Epidemic
2 million
opioid-
dependent
Americans
1,000
emergency
department
visits daily
Amount of
opioids
prescribed
has
quadrupled
25% of
people who
receive
long-term
opioid
treatment
will struggle
with
addiction
More than
40 people
die every
day from
opioid
overdoses
involving
prescription
opioids
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Historical Perspective of the Crisis
1986
1998
2000
2004
2010
2016 2017
2018
2019
National Institutes
of Health
Developed a
consensus focused
on causes of under-
treatment of pain
Concern about
addiction and
respiratory
depression
VHA
Issued a consensus
statement on assessing
pain in the patient with
impaired communication
Joint
Commission
Released 6
new standards
regarding pain
Veterans Health
Administration (VHA)
Established pain
management as a
national priority – the
Fifth Vital Sign
Opioid crisis labeled
national emergency
Maine mandates EPCS
Centers for Disease
Control and Prevention
Guideline for the prescribing
opioids for chronic pain
New York mandates EPCS
(I-STOP)
Veterans Affairs/
Department of Defense
Updated clinical practice
guidelines for the
management of opioid
therapy for chronic pain
SUPPORT for
Patients &
Communities Act
signed
Connecticut mandates
EPCS
Upcoming EPCS Mandates:
• 2019: Arizona
• 2020: Iowa, New Jersey,
North Carolina, Rhode
Island, Tennessee, Virginia
• 2021: Medicare
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Increased Visibility & Collaboration
Improve
Patient
Safety &
Drug
Utilization
CMS
PHARMA
CDC
PBM
State
HCA
Healthcare
DEA
FDA
CMS: Centers for Medicare &
Medicaid Services
CDC: Centers for Disease Control
PBM: Healthcare/Pharmacy Benefit
Manager
DEA: Drug Enforcement Agency
FDA: Food & Drug Administration
PHARMA: Pharmacy companies
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HCA Physician Services Group
13M
patient encounters
20,344
employees
1,095
practices
115
urgent care centers
3,324
residents in 233
programs
5,687
employed or
managed providers
1,700
providers recruited
annually
4,433
providers in joint-
ventures
* Figures above are 12-month trailing through December 2018
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Start of a Journey
Development of Controlled
Substance Guidelines
• PDMP Check Quarterly
• Controlled Substance
Agreements/Contracts
• Drug Screens / Pill Counts
• Require Monthly Chart Audits for
Patients with Pain Rx > 90 days
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Data Analytics & Opioid Prescribing
Moving Toward Data
Analytics:
• Standardizing workflows
& expectations
• Development of an
enterprise data
warehouse (EDW) and
data architecture
– Drug class
crosswalk
– Morphine Milligram
Equivalent (MME)
algorithm
Approach to Opioid
Prescribing:
• Develop medication-
specific analytics
identifying prescribing
trends & outliers
• Focus on data analytics
goals
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Report Development and
Workflow Standardizations
Report
Development
• Defining the audience
• Developing the
structure
Standardizing Data &
Clinical Workflows
• Assessments
• Prescription Drug
Monitoring Database
(PDMP) check*
• Controlled Substance
Agreement Document*
• Electronic Prescribing of
Controlled Substances
(EPCS)**
*MACRA/MIPS Optional measure in 2019, Required in 2020
**Medicare/Medicare Advantage Requirement in 2021
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Sharing the Story
Launched with
leadership
Discussed at local level
Individual provider meetings
Support team
education
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Visualizations & Clinician Approach
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Visualizations & Clinician Approach
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Controlled Substance Prescribing Trends
Even with an increase in patient volume
• Percentage of patients receiving a controlled substance
prescription decreased
• Percentage of those that are >90 MME has also decreased
Patient
Visits
% Opioid
Prescriptions
% of CS Rx MME
>=90
Year 2016
8,388,555 7.7% 1.33%
Year 2017
8,777,638 6.3% 1.22%
Year 2018
10,153,509 5.4% 1.20%
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Physician Perceptions
Statement 1
Statement 2
Statement 3
Statement 5
Statement 7
“Appreciate that PSG
is addressing the
issue by developing
guidelines & policies
& monitoring
adherence.”
“In general, a
feeling of more
loss of autonomy.”
“We’ve had providers
that are just refusing
to see patients now if
they are on chronic
narcotics because of
the challenges.”
“The electronic
prescribing using the 2
step authentication has
saved tremendous time
and improved security.”
“Frustration in Missouri
lack of a simple to use
Rx tracking system
that does not require
extensive login to use.”
“Appreciate PDMP
regulations to allow
for surrogate or
delegates to assist in
monitoring”
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Ongoing Challenges
Prescriber
perception
State & Federal
legislative changes
EHR
technology
Provider & staff
communication
Payer &
Pharmacy
differences
Patient
expectations
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Discussion Time
• How do you monitor and what metrics do you use to monitor opioid
prescribing in your organization?
• What are some of the challenges your organization has to overcome in
regards to controlled substance prescribing?
• What opportunities do we have as a healthcare IT community to
collaborate and develop broad based solutions to address the opioid
epidemic?
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Summary & Lessons Learned
Start small – but
start somewhere
Use your
resources &
professional
network
Clinician, operations, & IT
champions are invaluable
Leverage
technology
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• A: State Legislative Changes
• B: Next Steps for PSG
Appendices
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State Legislative Changes
http://amcp.org/policy-issues-advocacy/Federal-State-Legislative-Regulatory-Issues/
From January to August
2018, state legislatures
enacted over 75 new
opioid abuse
prevention bills
Prescribing guidelines & limits
Naloxone & rescue drug accessibility
Prescription Drug Monitoring Programs
(PDMP)
Continuing education for prescribers
Safe disposal of
controlled substances
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Next Steps for PSG
Expanding Controlled Substance
Prescribing
• Combination prescribing
• High Risk patient population
• Compliance with CS contract
• Compliance with PDMP
Quarterly check
HCA Physician
Services Group
Where this is heading:
Payer Reporting
• MACRA/MIPS
• Commercial P4P
• ACOs
More state regulations
More EPCS required
Identifying additional
uses of medication
analytics
• Antimicrobial
stewardship
• Vaccine
compliance
